Electronic Health Record Adoption: Perceived Barriers and Facilitators

Transcription

1 Electronic Health Record Adoption: Perceived Barriers and Facilitators A Literature Review April 2010

2 Centre for Military and Veterans Health University of Queensland Node Electronic Health Record Adoption: Perceived Barriers and Facilitators A Literature Review April 2010 Cristina Cotea, Research Coordination Unit, CMVH Centre for Military and Veterans Health 2010 Centre for Military and Veterans' Health The University of Queensland Mayne Medical School Herston Road, Herston QLD 4006 Phone Fax [email protected]

3 EHR Adoption: Perceived Barriers and Facilitators 1 Table of Contents 2 Abbreviations Executive Summary Introduction Methods Results Perceived Barriers to EHR Adoption Personal Barriers Organisational Barriers Perceived Facilitators of EHR Adoption EHR Adoption Predictors Attitudes towards EHRs by Stakeholder Type Primary Care Physicians Multispecialty Physicians Nurses Patients Other Stakeholders Addressing Barriers: Recommendations from the Literature Appendix A: Summary of Included Studies References

4 EHR Adoption: Perceived Barriers and Facilitators 2 Abbreviations CPOE EHR EPR GP HIT HP IT Computerised Provider Order Entry Electronic Health Record Electronic Personal Record General Practitioner Health Information Technology Health Practitioner Information Technology 4

5 EHR Adoption: Perceived Barriers and Facilitators 3 Executive Summary The Centre for Military and Veterans Health has conducted a literature review to identify the current knowledge related to perceived barriers and facilitators to the adoption of electronic health records (EHRs). While EHRs promise to improve healthcare delivery, efficiency, quality and safety, these improvements will occur only if health practitioners have access to the key functions they expect, and use them regularly. To guarantee the success of an EHR system implementation, it is therefore essential to have a good understanding of the factors that contribute to stakeholders adoption of EHRs. This report presents an overview of these factors as perceived by the stakeholders involved in EHR implementations, from an international perspective, in various clinical settings. While not all findings can be generalisable to the Australian context, they can be used as an inventory of commonly reported factors affecting EHR adoption to be considered when exploring change management strategies designed to increase EHR adoption. KEY FINDINGS A total of 51 studies measuring perceptions of factors affecting EHR adoption were included in the review. Of these, 43 studies focused on health practitioners and other healthcare staff perceptions 1-43, while the other 7 focused on patients perceptions The majority of studies (82%) were conducted in the US, while the remaining studies were from Australia, Austria, Canada, Hong Kong, New Zealand, Sweden and the UK. This suggests that some findings presented in this report could be specific to the US healthcare context, that doesn t rely extensively on general practitioners (GPs) to deliver a broad range of services, as opposed to the other countries. The US context also differs from other countries in the way primary care doctors are paid and in the fact that a high percentage of the population is uninsured. In spite of these differences, the findings suggest that most of the common themes reported in the US studies were present in studies from other countries. The common themes for factors affecting EHR adoption have been summarised below. They include nine personal perceived barriers to EHR adoption, five organisational barriers, seven perceived facilitators and ten EHR adoption predictors. Perceived Personal Barriers to EHR Adoption 1. Disruption of clinical workflow; 2. Lack of understanding of benefits; 3. Confidentiality, privacy and security issues; 4. Usability and flexibility issues; 5. Lack of time for training and re-designing workflows; 6. Lack of computers skills; 7. Negative impact on interactions between health practitioners and patients; 8. Patient resistance; 9. De-skilling. 5

6 EHR Adoption: Perceived Barriers and Facilitators Perceived Organisational Barriers to EHR Adoption 1. Financial costs; 2. Lack of adequate IT resources; 3. Implementation complications; 4. Software design and testing issues; 5. Lack of standardisation and interoperability. Perceived Facilitators to EHR Adoption 1. Motivation and incentives of the users; 2. Conservation of physician time; 3. Complementary changes in clinical workflow; 4. Facilitated selection of suitable EHR system; 5. Demonstrated utility of EHRs; 6. Adequate IT resources; 7. Reassurance regarding confidentiality and security issues. EHR Adoption Predictors 1. Practice size and type; 2. Understanding of benefits; 3. Technology readiness; 4. Physician specialty; 5. Age; 6. Experience; 7. Practice location; 8. Patient / provider ratio; 9. Financial resources; 10. Cooperative organisational culture. Attitudes towards EHRs were also summarised by stakeholder type: primary care physicians, multispecialty physicians, nurses, patients and other stakeholders. This presentation of the findings may be useful for devising EHR adoption strategies tailored to the needs of each stakeholder. The following concerns were found to be common among each stakeholder group: Physicians in Primary Care Disruption of clinical workflow resulting in loss of productivity; Usability and flexibility issues; Negative impact on interactions between HPs and patients; Physicians of all Specialties Financial costs associated with EHR implementation and maintenance; Technical organisational issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; Disruption of workflow resulting in loss of productivity. 6

7 EHR Adoption: Perceived Barriers and Facilitators Nurses Lack of adequate IT resources such as computers, training, technical support; Lack of technical skills and time available for training; Disruption of clinical workflow resulting in decreased time spent with patients. Patients Privacy and data security issues; Unauthorised sharing of their personal health information stored in their EHR; Inability to access and control access to their EHR; Other Stakeholders involved in EHR Implementation Financial costs associated with EHR implementation; Technical issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; Physician resistance. A summary of recommendations from the literature for addressing the perceived barriers has also been included at the end of this report. These recommendations were grouped under four themes: Strong leadership, that results from: (i) the presence of an EHR champion, Senior user or problem solver at each practice that has received extensive technical training and has acquired a deep understanding of the benefits associated with EHR implementation; and (ii) the use of different styles of leadership depending on the EHR implementation stage. Strong project management techniques, to ensure that: (i) the EHR vision is shared and understood by all and clinical input is included in the IT planning process; (ii) adequate support is available to reduce perceived barriers such as redesigning the clinical workflow to accommodate the EHR system; and (iii) EHR adoption strategies are tailored to the needs of each stakeholder type. Personalised, effective training and education, to ensure that: (i) all clinicians have a good understanding of the benefits to be realised by adopting EHRs, regardless of their respective roles in the clinical practice; (ii) adequate training is offered to users based on their needs; (iii) training is delivered without affecting clinicians productivity levels; and (iv) extensive, responsive technical support is available during early stages of implementation. Establishment of standards, that will reduce issues related to lack of standardisation and interoperability. In summary, the literature findings suggest that EHR adoption is affected by a combination of barriers, facilitators and adoption predictors. Hence, change management strategies and interventions designed to increase EHR adoption need to follow a holistic approach, addressing the multitude of personal and organisational factors applicable to the specific stakeholder type and healthcare setting. 7

8 EHR Adoption: Perceived Barriers and Facilitators 4 Introduction Electronic health records promise to improve healthcare delivery, efficiency, quality and safety. However, these improvements will occur only if health practitioners have access to the key functions they expect, and use them regularly. To guarantee the success of an EHR system implementation, it is therefore essential to have a good understanding of the factors that contribute to stakeholders adoption of EHRs. The purpose of this literature review was to: (i) identify the current knowledge related to attitudes towards electronic health records from different stakeholder perspectives, with a focus on the Australian context; and (ii) identify recommendations from the literature on successful change management strategies that could be implemented through the EHR design and implementation stages to increase adoption of the system. The research question for this literature review was: What are the perceived barriers and facilitators to electronic health record adoption? 5 Methods A comprehensive literature review of peer reviewed literature was undertaken to identify the current state of knowledge related to factors affecting EHR adoption, as perceived by the different groups of stakeholders involved in EHR system implementations. The bibliographic database Ovid Medline was searched in January 2010 articles published since 2000 using a combination of the MeSH terms Medical Records Systems, Computerized, attitude, attitude of health personnel, attitude to computers, and the keywords electronic health record, accept*, adopt*, attitud*, perception*. The resulting 97 articles were limited to the English language and studies on humans, yielding 91 articles. An additional 58 articles were retrieved following a Google Scholar search and a review of references from the included Medline articles. Inclusion Criteria Each title and abstract was reviewed and designated for inclusion, exclusion or further examination. Inclusion was based on the following criteria: The study reported attitudes towards EHRs from stakeholders involved in EHR implementation and use, focused on perceived barriers or facilitators to EHR adoption based on self-report data, or adoption predictors were inferred from self-report data; The study reported other attitudes towards patient-accessible EHRs (including perceived benefits of EHRs or satisfaction levels); The article reported final results of studies that measured attitudes towards EHRs (e.g. original research or review of several studies); Systematic reviews and comprehensive literature reviews were included. 8

9 EHR Adoption: Perceived Barriers and Facilitators Exclusion Criteria Research articles were excluded if they: Did not report perceived barriers, facilitators or adoption predictors of EHRs or other attitudes towards patient-accessible EHRs. Reported preliminary results of studies related to attitudes towards EHRs (e.g. conference proceedings, poster); Provided anecdotal information (i.e. not measured); Were duplicates. A total of 51 studies measuring attitudes towards EHRs were included in this literature review. Of these, 43 studies reported on health practitioner or healthcare staff attitudes towards EHRs 1-43, while the other 7 reported on patient attitudes towards EHRs In addition, two relevant systematic reviews were identified: one was focused on EHR adoption in the US, and the other was focused on lessons learned from EHR implementation experiences in 52, 53 seven countries. While these reviews did not focus on the perceptions of stakeholders involved in EHR implementations, they were useful for guiding the direction of the recommendations provided at the end of this report. The 51 studies identified were further categorised from several perspectives to gain insight into the review: Healthcare setting (community physician offices, hospitals, mixed); Study subjects (primary care physicians, specialists, nurses, patients, other stakeholders involved in EHR implementation and use); Country (Australia, Austria, Canada, Hong Kong, New Zealand, Sweden, UK, US); Study method (survey, questionnaire, interview, focus group, observations; study conducted pre- or/and post-implementation); Measurements (perceived barriers, perceived facilitators, adoption predictors, other attitudes). A summary of these studies by category is included in Table 1 on the next page, and a structured summary of each study has been included in Appendix A. 9

10 EHR Adoption: Perceived Barriers and Facilitators Table 1: Summary of Papers included in the Literature Review Articles reviewed (title and abstract) 146 Included after review: studies measuring attitudes towards EHRs 51 Health practitioners (and other healthcare staff) By healthcare setting: 1, 4, 14, 20, 22-26, 30, 40 Community Physician Offices Study Subjects: 1, 4, 14, 20, 22-26, 30, 40 Primary care physicians - Medical students 30 4, 31 Primary care nurses Other stakeholders: Managers / administrators / senior clinicians Administrative staff 40 Country: UK 4 1, 14, 20, 22-26, 30, US Method: Interview 4, 25, 26 1, 14, 20, 22-24, Survey Measurements: Predictors 1, 14, 20, , 14, 25, 26, 30, Barriers, 25, Facilitators 26 14, 30, Other attitudes Implementation stage: pre- and post- 1, 14 4, 25, 26, 30, post- 7, 10, 12, 21, 27, 38, 42 Hospitals Study Subjects: 7, 10, 27 Physicians 10, 27 - Residents 7, 16 Nurses Pharmacists 7 Other stakeholders: Managers / administrators / senior clinicians Country: Australia 7, Canada 38 10, 12, 16, 21, 27, 42, US Method: Focus groups 7, Interviews 7, 42 10, 16, 21, 27, 38, Survey Measurements: Predictors 12, 21 7, 10, 12, 16, 38, 42, Barriers, 10, Facilitators 12 10, 16, 27, 42, Other attitudes Implementation stage: pre- and post- 10, 12, 42, pre- 7, 38 16, 27, post- 4, 25, 26 7, 12, 21, 38, 42 3, 5, 6, 8, 9, 11, 13, 15, 17-19, 28, 29, 31-37, 39, 41 Mixed (Community offices and hospitals) Study Subjects: 15, 18, 19, 29, 31, 33, 37, 39 Primary care physicians 3, 5, 6, 8, 9, 11, 13, 15, 17, 31, Mixed physicians (primary care and specialists) - Emergency physicians 3 - Residents 31 3, 31, 33, 37 Nurses Other stakeholders: Managers / administrators / senior clinicians / project 28, 32, 37, 41 management team / technical staff Administrative staff 37 Country: Austria 8, Canada 37, Hong Kong 17, New Zealand 15, Sweden 9, 3, 5, 6, 11, 13, 18, 19, 28, 29, 31-36, 39, 41 US Method: Focus groups 41, Interviews 6, 8, 28, 32, Observation 31, Site Visits 5, 3, 5, 6, 9, 11, 13, 15, 17-19, 29, 33, 39 Survey Measurements: Predictors 3, 5, 6, 13, 17, , 6, 8, 11, 13, 15, 17-19, 28, 29, 31-36, 39, 41, Barriers, 5, 17, 31, Facilitators , 11, Other attitudes 6, 11, 13, 19, 28, 29, 32, 34-36, 39 Implementation stage: pre- and post, 3, 5, 9, 15, 18, 31, 33, 37, post- 41, pre Patients Country: Australia 50, Canada 44, 46, New Zealand 49, 51, UK 47, US 45, 48,

11 EHR Adoption: Perceived Barriers and Facilitators 6 Results A review of the literature has identified several common themes for factors affecting EHR adoption, as perceived by stakeholders. They include several perceived barriers to EHR adoption at the personal and organisational level, perceived facilitators and EHR adoption predictors. A summary of attitudes towards EHRs by stakeholder type (primary care physicians, multispecialty physicians, nurses, patients and other stakeholders) was also included to provide an overview of the main concerns among these different groups. 6.1 Perceived Barriers to EHR Adoption Common themes surrounding personal and organisational barriers to EHR adoption were reported in the literature, from studies measuring stakeholders perceptions. The resistance to change or EHR adoption by stakeholders can be attributed to these perceived negative effects of EHRs at the personal and organisational levels Personal Barriers Personal barriers to EHR adoption are related to professional and psychosocial factors that influence attitudes towards EHRs, primarily of those stakeholders that are using the EHR system. Nine key personal barriers to EHR adoption emerged as persistent themes from the literature review: (1) Disruption of Clinical Workflow. Health practitioners may be reluctant to adopt the EHR system if they believe that it will interfere with their workflow, productivity and efficiency, and take time away from patient care. Some HPs even reported concerns that this disruption of clinical workflow could lead to dissatisfaction with practice situation, 6-8, 10, 11, 14, 17, 18, 22, 25, 28, 31-34, 37, 39, 42 and decreased revenues. (2) Lack of Understanding of Benefits. Difficulty perceiving usefulness of EHRs such as improvement in quality of care can lead to HP resistance to change. Some HPs reported uncertainty about return on investment, and concerns over the introduction of clinical 5, 8, 10, 12-14, 17, 19, 21, 25, 31, 32, 39 errors. (3) Confidentiality, Privacy and Security Issues. Some stakeholders are concerned about unauthorised access to patient data due to hackers or identity theft and corruption or 7, 8, 10, 14, 21, 22, 35, 39, 42 alteration of the data. (4) Usability and Flexibility Issues. Most HPs are concerned that the EHR system could be too difficult to use or it could lead to redundant data entry. For example, data entry and coding can be too difficult in the fast pace of a primary care practice and free text could be preferred in certain cases. Other concerns were reported regarding the lack of flexibility of EHR due to inapplicability of certain features or unavailability of appropriate 4, 8, 15, 18-20, 22, 25, 31 options. (5) Lack of Time. Some HPs believe they lack the time required to acquire knowledge about 7, 11, 17, 22, 31, 33, 37, 42 systems through training and redesign clinical workflows. (6) Lack of Computer Skills. Some HPs feel that their inability to type quickly enough and 6, 7, 14, 18, 22, 35, 42 general lack of comfort with IT could act as a barrier to EHR adoption. 11

12 EHR Adoption: Perceived Barriers and Facilitators (7) Negative Impact on Interactions between Health Practitioners and Patients. Concerns have been expressed around the negative impact of EHRs on HPs interaction with patients and other HPs. Some HPs are concerned that EHRs will create a shift in the physician-patient relationship which will result in a loss of HP control and a shift in work 7, 8, 14, responsibilities which will result in HPs becoming an expensive order entry clerk. 18, 30, 31, 33 (8) Patient Resistance. HPs are concerned that patients will be opposed to their use of the EHR. Some HPs have also expressed concerns about EHRs affecting their communication with patients such as loss of eye contact, which is against the social norm for physicians to avoid using the computer while with the patient. 22 (9) De-skilling. Some HPs were concerned of becoming dependent on the EHR system. Nurses thought that the EHR could limit their critical thinking and charting accuracy if they relied too heavily on the system. More experienced HPs feel that this could cause a serious concern for younger HPs that could become reliant on the decision support 7, 16 available within the EHR Organisational Barriers Organisational barriers to EHR adoption are related to financial and technical factors affecting attitudes towards EHRs, primarily of those stakeholders involved in implementing EHR systems. Five key organisational barriers to EHR adoption emerged as important themes in the literature: (1) Financial Costs. The most common organisational concern reported was around financial costs associated with all stages of the EHR implementation such as planning, consulting services, start-up, purchasing of hardware and software, and ongoing costs for training and 5-8, 11-14, 17, 19-22, 25, 28, 35, 39, 54 maintenance. (2) Lack of Adequate IT resources. Concerns have been reported regarding the availability of 6, 7, 10-13, 17, 33, 35, 42 workstations, printers, internet connections, training and technical support. (3) Implementation Complications. There is a concern that the organisation will be unable to select an EHR system that meets the needs of HPs due to an overwhelming number of EHR vendors, most of them transient or volatile. Concerns were also reported surrounding conflicting priorities between the organisation as a whole and individual clinicians during the selection process of the EHR system and differences over software development priorities. 5-8, 14, 22, 25, 32, 33, 35, 38 (4) Software Design and Testing issues. Concerns were reported regarding the technical limitations of computers such as slow systems, system downtime and software design problems not indentified during early testing. Another concern from HPs was around system designers misunderstanding of clinical processes resulting in usability and flexibility issues. Clinicians working on template design felt that not have access to a working prototype had a 7, 10, 14, 16, 18, 33 negative impact the EHR system design. (5) Lack of Standardisation and Interoperability. The challenges associated with using these non-interoperable EHR systems such as inadequate electronic data exchange may negatively impact workflow and productivity, which in turn contribute to clinicians resistance to adopt 5, 12-14, 25, 28, 35, 39 these systems. 12

13 EHR Adoption: Perceived Barriers and Facilitators 6.2 Perceived Facilitators of EHR Adoption Facilitators are initiatives or actions from healthcare organisations or governments related to EHR system implementation that could lead to increased adoption of EHRs. Several key perceived facilitators have been reported in the literature: (1) Motivation and Incentives of the Users. Health practitioners believe that financial incentives for EHR implementation and quality performance have the potential to influence EHR 5, 12, 17 adoption. (2) Conservation of Physician Time. HPs believe that healthcare organisations implementing EHRs need to address workstation availability and system speed issues and minimise time required by HPs to document care. For example, it was suggested that in the case of clinical decision support features such as reminders, limiting the number of reminders following review by a committee can facilitate their effective use and eliminate reminder burden. Another example is the strategic placement of the computer workstations to facilitate the effective use of clinical reminders and patient-physician communication during patient 10, 31 visits. (3) Complementary Changes in Clinical Workflow. HPs suggest that healthcare organisations must take steps to ensure that they understand physician workflow and build EHR systems that facilitate this workflow. Examples of complementary changes in clinical workflow include entering data from patient paper charts into the EHR, creating customised templates for the record, creating documentation shortcuts, obtaining adequate technical support and consultation, reorganising workflow in the examination room and in the practice to accommodate EHRs and integration of clinical reminders in the workflow. In addition, programs and interventions intended to increase adoption should help HPs modify their 31, 40 workflow to accommodate EHRs and to get the most out of the system. (4) Facilitated Selection of Suitable EHR System. The availability of certified products that guarantee a minimum level of EHR functionality is believed to contribute to increased adoption of EHRs. Other suggestions include educational programs to inform HPs about the EHR system selection process and provide them with a list of standardised questions to ask EHR vendors. HPs also believe that the EHR system selection should be participatory, involving local leaders and clinicians, to allow staff to provide input into the decision and feel that their input has been noted. Finally, extensive software testing is required to avoid users frustration with software problems which can quickly escalate to the entire EHR system and 12, 40 result in resistance to implementation. (5) Demonstrated Utility of EHRs. HPs need to be presented with evidence of the utility of EHRs to HPs. A targeted, educational effort to show the advantages of EHRs that includes demonstrations of a system prototype may be useful for improving acceptance of the system. Evidence-based protocols and data collected post-implementation could document the utility of EHRs. 17 (6) Adequate IT Resources. Technical support provided during implementation and a problem reporting system that allows HPs to document problems and receive prompt feedback are believed to increase EHR adoption. Other IT facilitators include flat-screen monitors on mobile arms, convenient availability of computers at numerous locations in the medical 12, 31, 40 office, in the hospital and at the homes of on-call physicians. (7) Reassurance Regarding Confidentiality and Security Issues. HPs believe that healthcare organisations need to pay more attention to confidentiality and security issues in order to convince HPs that these issues have been addressed. Another suggestion consists of protecting practitioners from personal liability for record tampering by external parties. 5 13

14 EHR Adoption: Perceived Barriers and Facilitators 6.3 EHR Adoption Predictors Most of the studies also reported EHR adoption levels in the clinical settings studied. The following list includes key factors that were associated with a higher level of EHR adoption with health practitioners: (1) Practice Size and Type. HPs practising in larger groups, being based at hospitals or medical centres seem to be driving EHR adoption. It was suggested that this reflects the greater availability of the financial resources required to acquire an EHR system at these sites. Physicians located in areas with higher physician concentration and more competition were 1, 5, 6, 12-14, 17, 19, 28, 29, 34, 35, 52 found to be more likely to adopt EHRs. (2) Understanding of Benefits. HPs that had a good understanding of the quality of care improvements resulting from EHR use or those involved in IT planning were more likely to be high users of EHRs. Organisational engagement in quality improvement is also a predictor of 3, 13, 17, 21, EHR adoption. (3) Technology Readiness. Positive attitudes about the influence of computers on health care and experience with existing system positively influences EHR adoption. Those HPs who are already using online scheduling and billing systems show less resistance to technologyrelated changes. Placement of strategic importance on IT by the organisation was likely to 1, 3, 13, 21, 22, 34 result in higher EHR adoption. (4) Physician Specialty. The higher the level of technology dependency in a specialty, the more likely HPs will be comfortable accepting technology related changes in their workplace. Some studies have reported that primary care physicians were less likely to adopt EHRs compared to specialists. In addition, general paediatricians were significantly slower to incorporate EHRs into their office practice than other physicians, while imminent adopters were more likely to be practising family medicine or obstetrics/gynaecology. This could also be explained by the observed marked differences in attitudes towards EHRs between GPs 15, 20, 22, and specialists. (5) Age. Younger HPs are generally more likely to adopt EHRs. However, a study reported that 1, they are less likely to become high users of EHRs once adopted. (6) Experience. Studies have shown that residents and recent graduates have more positive attitudes towards EHRs and practices that teach medical students or residents were more 10, 30, 35 likely to have an EHR. (7) Practice Location. HPs practising in urban setting were more likely to adopt EHRs, suggesting that the introduction of EHRs is likely to widen the digital divide between rural and urban HPs. 23 (8) Patient / Provider Ratio. HPs seeing fewer patients were more likely to have adopted EHRs, suggesting that HPs working in busy offices or hospitals may be more resistant to EHR implementation. (9) Financial Resources. HPs with an increased number of patients on Medicare were significantly more likely to adopt EHRs than those with low volume of Medicare patient panels. Different financial considerations exist in HP s private office or in a governmentfunded hospital. Initial and ongoing maintenance cost is a big issue that physicians do not have to deal with if they are working in a hospital. 14

15 EHR Adoption: Perceived Barriers and Facilitators (10) Cooperative Organisational Culture. A cooperative culture within the HP practice can minimise active resistance to EHRs. However, it can also inhibit criticism before and during implementation, thus depriving decision makers of important feedback. 32 An understanding of the impact of the above predictors on EHR adoption may assist healthcare organisations as they work to increase EHR adoption rates. 6.4 Attitudes towards EHRs by Stakeholder Type This section summarises the literature findings for each group of stakeholders involved in EHR implementation and use, such as primary care physicians, multispecialty physicians, nurses and patients. A comparison of specific attitudes towards EHRs reported for each stakeholder group provides a more robust estimate of the barriers to EHR adoption and could be useful in devising strategies tailored to these groups based on their perceived barriers and needs Primary Care Physicians 1, 4, 14, 15, 18 studies of primary care physicians attitudes towards EHRs were reported in the literature 18-20, 22-26, 29-31, 33, 37, 39, 40 1, 4, 14, 20,. Nine of these studies were conducted in community physician offices 22-26, 30, 40, while the other eight were conducted in a mixed healthcare setting consisting of both community offices and hospitals 15, 18, 19, 29, 31, 33, 37, 39. One of these 18 studies examined medical students attitudes towards EHRs. 30 KEY FINDINGS Major concerns among primary care physicians: Disruption of clinical workflow resulting in loss of productivity; Usability and flexibility issues; Negative impact on interactions between HPs and patients EHR Adopters vs. Non-adopters Studies comparing attitudes among EHR adopters and non-adopters in primary care suggest that the two groups perceive EHRs differently. This information can be useful for determining the most important barriers to EHR adoption, as perceived by non-adopters. A US study compared perceived barriers among general paediatricians with and without an EHR in their practice. 14 The perceived barriers common among both groups included the cost of implementing and maintaining the EHRs, increased physician workload and physician resistance. Those without an EHR mentioned other barriers such as being unable to select an EHR system that meets their paediatric-specific requirements, concerns regarding system downtime and a lack of understanding of benefits resulting from EHR implementation. Perceived benefits of EHRs included improved practice operation, long-term savings and improved quality of care. An interesting finding 15

16 EHR Adoption: Perceived Barriers and Facilitators of this study was that paediatricians without an EHR were less likely to believe in benefits resulting from EHR system implementation. Another US study reported that there were large differences in GPs perceptions of barriers to EHR adoption between users and non-users of EHRs. 19 Overall, the perceived barriers to EHR adoption reported by non-users were a lack of understanding of the benefits resulting from EHR implementation, usability issues, cost, and confidentiality and security issues. A large US study identified several perceived barriers to EHR adoption among GPs who had not adopted EHRs. The main perceived barriers to EHR adoption among non-adopters were concerns about financial costs, workflow barriers and loss of productivity, implementation complications and 39 security and privacy issues. The authors also reported that more than 264 unique types of EHR/EMR software implementations were found. This low rate of standardisation was also considered a major barrier to EHR proliferation, as it results in a great devaluation of existing implementations. Several US studies of primary care physicians revealed that the practice size has an impact on physicians attitudes towards EHRs. The results suggest that primary care physicians practicing in 1, 20, 22-24, larger groups are more likely to be interested in utilising EHRs. 29 In addition, technology readiness was found to be the strongest predictor of EHR adoption in this primary care setting Post-implementation Attitudes The most common theme among studies of primary care stakeholders perceptions following the implementation of an EHR system is around the negative impact of EHRs on the clinical workflow and overall productivity. A US study reported the perceptions of primary care physicians, nurses and physician assistants serving minority populations, following the implementation of a large-scale EHR system based on VistA (the EHR system used by the US Veterans Health Administration). The perceived barriers reported by this group were clinical productivity loss, technical limitations of computers and availability of technical support. 33 Adoption predictors included increasing years since completion of clinical training and positive attitudes towards EHRs improving quality of care. The study suggests that clinicians support the use of IT to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential, due to limited use of key functions within the EHR. Interviews with a group of primary care physicians and managers following implementation of an EHR system suggests that a successful re-design of clinical workflow to accommodate the EHR and 25, 26 more intensive EHR use are associated with greater quality of care and financial benefits. Perceived barriers reported by this group were financial costs, disruption of clinical workflow, usability issues, lack of time and support to re-design clinical workflow, and lack of standardisation and interoperability. An observational study of the use of clinical decision support by GPs and nurses at Veterans Administration medical centres in the US has confirmed some of the perceived barriers listed above. 31 The researchers observed how a failure to redesign the practice workflow resulted in a lack of coordination between nurses and providers, redundant documentation and the use of paperbased workarounds. During patient visits, GPs were less likely than nurses to use the computer 16

17 EHR Adoption: Perceived Barriers and Facilitators resulting in impaired data acquisition and implementation of recommended actions. This barrier was attributed to the belief by GPs in the social norm to avoid using the computer while with the patient. GPs complained about usability and flexibility issues with the clinical decision support module of the EHR system, such as being unable to provide the answers required by the system and having to make something up, and the inapplicability of the CRs to some clinical scenarios. Finally, GPs reported that slow processing speed or computer crashes can be paralysing as the clinicians are required to use the system for virtually all clinical functions. The researchers suggest that further attention to these factors when redesigning clinical workflows to accommodate the EHR can contribute to effective use of the EHR system. Two other common themes among studies of primary care stakeholders perceptions following the implementation of an EHR system are around usability issues and the negative impact of EHRs on the physician-patient interaction. The usability issue that has been commonly reported in the literature is related to the recording of structured information in the EHR, also referred to as coding. Interviews with a small group of GPs in the UK suggest that the recording of structured information in the EHR is perceived as a usability issue due to too many detailed options in the classification and the lack of definite meaning for each code. 4 The study findings suggest that the barriers to recording of structured data in the EHR by GPs are socio-cultural, mainly associated with the negative impact coding could have on the physician-patient relationship. Although they accept that coding is necessary for demonstrating evidence-based care, they believe it is inappropriate for documenting the complex social interaction in primary care and its associated diagnostic uncertainty. For GPs, free-text is a vital constituent of the EHR as it provides a more powerful reminder of the individual human encounter. A New Zealand study also reported that GPs and specialists found it difficult to code diagnoses in the EHR, and objected to coding being done primarily for administration, financial or statistical purposes, 15 rather than for individual patient care. The study respondents also felt that there was considerable delay in the flow of diagnostic information from the hospital to general practices, and favoured an electronic transfer of information. However, marked differences in the attitudes of GPs and hospital specialists were reported: most GPs embraced computers and diagnostic coding, whereas few hospital consultants did so. This difference was attributed to the fact that GPs have more investment in their EHR systems, while hospital specialists have the systems imposed by their hospital administration, with no facility for hospital doctors to add codes to the EHR. The study suggests that attitudinal differences between GPs and hospital specialists will need to be addressed to facilitate the flow of information between hospitals and general practices. GPs also feel that there are several social, workflow, technical and professional barriers to EHR use during patient visits. A US study reported that some of these concerns include loss of eye contact with patient, loss of efficiency and productivity, slow EHR system and inability to type quickly enough. 18 GPs also indicated a preference towards writing long prose notes and reported that using the computer in front of the patient was considered unprofessional. The authors suggest that these barriers need to be addressed to ensure EHRs are used in the presence of patients, which will in turn realise the full potential of in-office clinical support. 17

18 EHR Adoption: Perceived Barriers and Facilitators Medical students at US primary care clinics were also concerned that the EHR system will have a negative impact on the doctor-patient encounter, such as loss of eye contact and loss of communication with the patient. 30 Perceived benefits reported included improved organisation of information, and improved documentation and decision support. A US study investigated in more detail the effect of the EHR system on the physician-patient encounter, by conducting interviews, focus groups and observations in primary care offices. They identified 14 perceived facilitators grouped under four themes: spatial, relational, educational and 40 structural. Perceived spatial facilitators during patient visits included using flat-screen monitors on mobile arms (as opposed to large, fixed monitors located in the corner of the examination room), having computers conveniently available at numerous locations in the medical office, in the hospital and at the homes of on-call physicians to create seamless communication over time and location, and ensuring that patient records are reviewed by physicians prior to patient visits to minimise the impact of EHR use on the flow of the encounter. Perceived relational facilitators included the availability of flexible EHR templates to accommodate the complex social interaction in primary care, ensuring the physician s style when alternating between computer use and patient communication does not have a negative impact on the interaction, and ensuring physicians see the benefits of collaboration with patients and are willing to share the EHR screen with their patients. Perceived educational facilitators included advanced computer skills for all physicians using the EHRs, a training plan that addresses topics related to best-practices for EHR use during patient visits, educating the patient to ensure they have a good understanding of how the EHR is used in primary care. Perceived structural facilitators included availability of financial resources necessary for continuing technical updates, being able to record narrated notes in the EHR, organisational culture supportive of the EHR, and acceptance by physicians and patients that the EHR is a newly introduced technology that is still in its embryonic stages of development. A synthesis of the findings from three qualitative studies of Canadian family physicians and primary health care staff reported that perceived facilitators among this group were for: (i) the EHR implementation team to understand the needs and expectations of users, and baseline levels of computer knowledge, (ii) to dedicate time specifically for EHR training that will not impact on physicians productivity and (iii) to ensure an EHR champion or problem solver is available at the 37 practice site. 18

19 EHR Adoption: Perceived Barriers and Facilitators Multispecialty Physicians 17 studies of physicians from all specialties were reported in literature. 3, 5-11, 13, 15, 17, 27, 28, Two of these studies were conducted in hospitals 7, 10, while the other 15 were conducted in mixed healthcare settings (community offices and hospitals) 3, 5, 6, 8, 9, 11, 15, 17, 28, Two of these 17 studies 10, 27 examined residents attitudes towards EHRs. KEY FINDINGS - Major concerns among physicians of all specialties: Financial costs associated with EHR implementation; Technical issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; Disruption of workflow resulting in loss of productivity EHR Adopters vs. Non-adopters Similarly to the primary care setting, studies comparing attitudes among EHR adopters and nonadopters from all physician specialties suggest that the two groups perceive EHRs differently. A national survey in the US of physicians practicing in groups of three or more reported that the most important perceived barriers to EHR adoption were: (1) lack of support from practice physicians; (2) lack of capital resources to invest in an EHR; (3) concern about physicians ability to input into the EHR; (4) concern about loss of productivity during transition to EHRs; and (4) inability to easily input historic medical record data into the EHR. Another finding of this study was that larger practices were more likely to have adopted EHRs than smaller practices. Several studies reported findings from a recent survey of a large group of US physicians from all 11, specialties. Perceived barriers to EHR adoption were financial costs, training and productivity loss, lack of time to acquire knowledge about the EHR system, lack of uniform standards and a lack of computer technical support. Physicians also reported being generally satisfied with the EHR due to improved access to up-to-date knowledge, improved interactions with the healthcare team, reduction of medication, and improved efficiency and quality of care. The authors reported considerable variability in the functions available in the EHRs and the extent to which physicians use them, suggesting that the availability of EHR functions does not always translate to regular use in day-to-day practice. The study findings suggest that physicians most likely to be EHR adopters were from larger practices, other than primary care, affiliated with hospitals especially teaching hospitals, had more experience and had been practicing for a longer time and had a better understanding of EHR benefits. Incentives for quality of care were reported to facilitate EHR adoption. A state-wide survey in the US reported that important perceived barriers to EHR adoption were: (1) lack of technical support; (2) lack of industry standards; (3) interoperability concerns; (4) high upfront costs; and (4) physician scepticism. The researchers also established a profile of imminent adopters based on the findings. Imminent adopters were more likely to be younger, from practices 19

20 EHR Adoption: Perceived Barriers and Facilitators with multiple physicians, more experienced with technology and more often in practices engaged in quality improvement. A large study with Hong Kong physicians representative of the general physician population reported that the major perceived barriers were time costs associated with planning, purchasing, training and maintenance activities related to the EHR, large capital investments and maintenance costs, lack of technical support and lack of knowledge and perceived difficulty in learning new technology. The study findings also reported that an understanding of benefits and government financial incentives were perceived as facilitators to EHR adoption by the respondents Pre-implementation Attitudes A recent (2009) study conducted in a large Australian teaching hospital preparing to implement an electronic medication management system has confirmed the above findings are applicable to Australian health professionals. 7 The authors identified the following areas of concern: (1) change in workflow; (2) lack of adequate IT resources; (3) software issues; (4) negative impact on the patientphysician relationship; (5) lack of time to acquire knowledge about systems through training; (6) lack of computer skills; (7) de-skilling; (8) confidentiality, privacy and security concerns; (9) financial concerns; and (10) implementation complications. Similar findings were reported by a recent study in Austria exploring how change-barriers and resistance of GPs and specialists in private practice to the introduction of a nationwide EHR were 8 motivated by negative emotions. This fear and anxiety was related to uncertainty regarding the implementation, lack of knowledge, change of accustomed workflows, concerns of an increase in workload and cost, and concerns of confidentiality, privacy and security issues introduced by EHRs. To improve the physicians acceptance of the nationwide EHRs, the authors recommend the publication of documents outlining the benefits of the EHRs to physicians, and the introduction of information campaigns. The EHR system has to be made transparent to physicians to allow an informed discussion around the facts to take place, that will in turn address some of the concerns Post-implementation Attitudes A recent study of clinician perceptions of an EHR system during the first year of implementation in emergency services reported that EHR adoption was strongly associated with positive perceptions of training and support, and belief in usefulness of EHRs. 3 Many perceptions of the EHR system at launch persisted through the first months of use, suggesting that early positive impressions of training, support, and belief in EHR usefulness can maximise EHR adoption. A large nationwide survey of US physicians from all specialties, with a 50% representation from primary care, suggests that the most important perceived barriers among this group were: (1) financial issues; (2) concerns about findings a system that meets their needs; (3) uncertainty about their return on investment; and (4) concern that the system would become obsolete. Perceived facilitators were: (1) financial incentive for the purchase; (2) payment for use of EHR; and (3) protecting physicians from personal liability for personal record tampering by external parties. The authors also suggested that based on the findings, primary care physicians, and those practicing in larger groups, in hospitals or medical centres were more likely to use EHRs. 20

21 EHR Adoption: Perceived Barriers and Facilitators A study of Sweden physicians reported that frequent users of the eprescribing module of an EHR were more likely to show positive attitudes towards the EHR module than infrequent users. 9 These findings suggest that the uptake of EHRs may depend on users attitudes towards the system. Positive attitudes to the eprescribing module reported by this group were beliefs that it was easy to use, improved quality of care, saved time and it was safer compared to handwritten prescription. Negative attitudes included certain usability issues and concerns over the module s negative impact on the physician-patient relationship. A New Zealand study at a large hospital reported that hospital specialists were less likely to embrace computers and diagnostic coding, when compared with GPs from general practices in areas 15 surrounding the hospital. User acceptance of the EHR is higher among resident than faculty physicians, as reported by a study at a US teaching hospital. 10 The greatest perceived facilitator for these users was conservation of their time, including improving system speed, reducing time spent waiting for a computer to become available, and minimising time spent documenting care. Another US study at a teaching hospital compared the EHR satisfaction levels of paediatric residents 27 with internal medicine residents. While most users in both specialties were generally satisfied with the EHR and did not perceive it as a disruption in their usual practice patterns, the study reported that paediatric residents were more satisfied with template-based documentation than internal medicine residents Nurses 2-4, 7, 16, 31 Six studies reported specifically on nurses perceptions of barriers to EHR adoption. KEY FINDINGS - Major concerns among nurses: Lack of adequate IT resources such as computers, training, technical support; Lack of technical skills and time available for training; Disruption of clinical workflow resulting in decreased time spent with patients. Interviews with primary care nurses and GPs in the UK were conducted to identify the perceived barriers to recording of structured information (coding). 4 Nurses were concerned about the meaning and interpretation of this information by patients, which they believed may cause anxiety. As explained earlier in this report, doctors concerns were more around difficulties selecting a definite diagnosis. A recent study in an Australian hospital reported that nurses had several concerns regarding the introduction of EHRs. 7 The main concerns were around the lack of technical skills, lack of time available for training and the stress caused by the EHR implementation roll out. 21

22 EHR Adoption: Perceived Barriers and Facilitators An observational study of the use of clinical decision support by nurses at Veterans Administration medical centres in the US has provided some observational evidence for the concerns listed above. 31 Nurses lacked understanding of the importance of clinical reminders and perceived them as a timeconsuming, noncore work activity, which negatively affected the effective use of the system. A US survey of nurses perceptions of EHRs suggests that although nurses perceived that EHRs 16 affected their work and patient outcomes, they preferred the EHR over paper charts. The main perceived barriers were slow system speed, system downtime and lack of adequate IT resources. Some nurses felt that the EHR use was extensive and time-consuming and decreased time with patients, resulting in decreased quality of care. Positive effects on nursing work and patient outcomes were perceived to be increased access to patient information, increased efficiency, improved organisation and increased patient safety. A UK survey of nurses perceptions of the National Health Service modernisation programme that includes an EHR confirms that training is perceived as the major facilitator to EHR adoption among 2 this stakeholder group. The findings also suggested that nursing staff were not widely aware of the EHR implementation plans, and had a lack of understanding of benefits from EHR implementation. The authors concluded that it was important to engage with clinicians prior to the EHR design stage, to ensure that it is suitable for end users, and improve their understanding of the benefits resulting from EHR implementation. A survey of nurses perceptions of standardised care plans in EHRs in Sweden revealed several 43 positive attitudes. Nurses felt that standardised care plans could facilitate nursing practice by increasing nurses ability to provide the same high-quality basic care to all patients and decreasing documentation time as well as redundant documentation. The authors also highlighted the importance of providing nurses with training that will increase their knowledge of standardised care plans and help them better understand evidence-based knowledge. A survey of emergency nurses and physicians in the US suggests that the main adoption predictors in this healthcare setting were (1) perceptions of training and support; (2) perceptions of usefulness; (3) effort expectancy; (4) social influence; (5) computer literacy and (6) positive attitudes towards computers. The authors also reported that many perceptions of the EHR system at launch persisted through the first months of use, suggesting that early positive impressions of training, support, and belief and EHR usefulness can maximise EHR adoption. 22

23 EHR Adoption: Perceived Barriers and Facilitators Patients Eight studies reported on patients perceptions of patient-accessible EHRs KEY FINDINGS Major concerns among patients: Privacy and data security issues; Unauthorised sharing of their personal health information stored in their EHR; Inability to access and control access to their EHR; As with EHR adoption by HPs, the barriers to adoption by patients are not limited to technical ones. In addition to the economic and technological challenges, organisational and behavioural issues can delay the adoption of patient-accessible EHRs. A US nationwide study of public attitudes towards EHRs suggests that the American public shares concerns about adverse privacy and data security issues associated with the EHR. 45 Other concerns reported included an increase in medical records, a fear that patients will not disclose sensitive but necessary information if they know that it will be stored in an EHR, and a fear that existing federal health privacy laws will be reduced in the name of efficiency. A Canadian study has confirmed that patients are interested in having access to their health record online, especially for laboratory results. 44 The haematology patients felt however that they would require additional educational materials to understand the information in their EHR. They also expressed interest in online communication with their clinicians and in being able to modify their health information online Attitudes towards Computer Use by GPs during consultations An Australian study of patients attitudes towards computer use by GPs during consultations suggests that computer use by GPs does not tend to unsettle patients in their relationship with their doctor, as many GPs feared would happen. 50 On the contrary, computer use during consultations is perceived to have a positive impact on doctor-patient communication, quality of care and the overall consultation process. The only concern expressed by patients was around their lack of understanding about the computer s role during consultation. A Canadian study of seniors views of the EHR reported that they generally had positive attitudes regarding the use of computers and the EHR in their presence. 46 Seniors felt that the EHR allowed them to be better informed, and they placed their confidence in the professionals providing their health care and services. They also appreciated the innovation of EHRs. 23

24 EHR Adoption: Perceived Barriers and Facilitators Attitudes towards Sharing Confidential Personal Health Information held in EHRs A New Zealand study explored patients attitudes towards sharing their health information held in EHRs. 49 The respondents indicated that they would like limitations to be placed on the distribution of their personal information particularly for purposes other than clinical care. Factors that had an impact on patients attitudes were the identity of the recipient, the level of anonymity of the shared information and the type of information requested. The authors suggested that these findings could be useful for developing an e-consent framework for dealing with issues of consent related to sharing of health information held in EHRs. A more recent large New Zealand study explored public attitudes towards sharing confidential 51 personal health information held in EHRs. Preliminary findings suggest that there are four attributes that have an impact on the public s attitudes: the level of identification, the role of the person accessing the information, their reason for accessing it and the extent of information requested. Identification by medical record number (or no identification) was the preferred option when medical records were accessed for any reason other than clinical care by a doctor, nurse or paramedic Attitudes towards Having Access to their Electronic Health Record A large UK study reported that a majority of patients believed they should have access to their health record held in the EHR and be able to control access to their records. 47 When given access to their health record online as part of a feasibility study, patients felt the session was useful and found the records easy to understand. A few patients did not want access to their EHRs because they trusted their GP and thought it would imply a lack of confidence. A large US study reported that patients had positive attitudes towards having access to an EHR 48 medications module. They felt that the module was easy to use, improved their preparedness for their next visits and allowed their providers to have access to more accurate patient information Other Stakeholders Nine studies reported specifically on the attitudes towards EHRs of practice managers, hospital 4, 7, 12, 21, 28, 32, 38, 41, 42 administrators, senior clinicians, EHR implementation team and technical staff. One of these studies was conducted in community offices 4, five in hospitals 7, 12, 21, 38, 42 and the other three in mixed healthcare settings 28, 32, 41. KEY FINDINGS Major concerns among management, administration and EHR implementation team members: - Financial costs associated with EHR implementation; - Technical issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; - Physician resistance. 24

25 EHR Adoption: Perceived Barriers and Facilitators EHR Adopters vs. Non-adopters A recent national survey of hospital executives in US acute care hospitals reported that the most important perceived barrier was the cost associated with the implementation of EHRs, more specifically capital requirements and high maintenance costs. 12 Other concerns reported included physician resistance, unclear return on investment and lack of availability of IT staff. The main perceived facilitators to EHR adoption were additional reimbursement for EHR use and financial incentives for EHR adoption. Other facilitators of adoption included the availability of technical support and objective third-party evaluation of EHR products. A US study based on self-report data from CIOs of acute care hospitals revealed that several factors can increase EHR adoption. These are: (i) physicians active involvement in clinical IT planning; (ii) placement of strategic importance on IT by the organisation; (iii) CIO involvement in patient safety 21 planning; and (iv) perception of an adequate selection of products from vendors. A US study examined users attitudes to the EHR implementation during transition from one EHR system to another, in a non-profit healthcare organisation (Kaiser Permanente). 32 The interviews conducted with senior clinicians, managers and project team members revealed that organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points. Many users perceived the initial selection of the system to have been detached from the local environment, which fuelled resistance. Problems with software design and development increased local resistance, as did clinicians reduced productivity during implementation. The system initially clarified and then changed roles and responsibilities often, though not always, for the better. The organisation s cooperative culture minimised overt resistance to change but also inhibited constructive feedback during implementation. Leadership also had varying effects: participatory leadership was valued during selection of an electronic system, but hierarchical leadership was valued during implementation. Interviews with key stakeholders in EHR implementations from a range of US healthcare organisations revealed that the major perceived barriers were (1) financial costs; (2) loss of productivity; (3) EHR implementation complications; and (4) lack of data standards and 28 interoperability. The authors also reported that EHR implementations varied considerably across stakeholders, suggesting the improvements in quality gained from one healthcare setting may be attenuated by the under-investment in other settings. Interviews with practice managers and medical directors, all part of an academic ambulatory care network associated with a large US teaching hospital, revealed that the perceived barriers to EHR adoption were concerns around loss of productivity during implementation, practitioner resistance, 42 lack of adequate IT resources and privacy and security issues. The main difference between adopters and non-adopters of EHRs was that those who had already adopted EHRs believed that the comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome Pre-implementation Attitudes A recent study in an Australian hospital reported that hospital executives and clinicians expressed similar concerns regarding the EHR implementation. 7 Hospital executives were mainly concerned about being able to provide access to sufficient IT resources (computers and other mobile 25

26 EHR Adoption: Perceived Barriers and Facilitators equipment) required following EHR implementation and about the costs associated with EHR system implementation and maintenance. A recent study of Canadian CEOs of general and acute care investigated organisational perceptions of patient-accessible EHRs. 38 The perceived barriers reported were lack of financial resources and clinician buy-in. The CEOs felt that clinicians would be less willing to provide access for patients to the full EHR, while being aware that patients would want access to the full record. The authors concluded that the best way to implement patient-accessible electronic health records is still being debated. A recent study in an Australian hospital reported that pharmacists had several concerns regarding the introduction of EHRs. 7 The main concerns were around the EHR s impact on workflow practices and communication between health professionals. There were also concerns around the confidentiality, privacy and security issues being introduced when patient medication details are being accessed using mobile devices. A Canadian study at a hospital haematology department has reported that staff members concerns regarding patient-accessible EHRs centred around issues of confidentiality, privacy and security issues. 44 Other perceived barriers were integration of new technology in existing systems, resistance to change in the system and providing adequate support and education. Staff members also felt that patient-accessible EHRs would lead to an increase in time required to manage patients such as handing questions and phone calls, and increased risks of breaches in security and confidentiality. Potential benefits included decreased workload, improved workflow, better management of patients and decreased unnecessary hospital visits Post-implementation Attitudes A small UK study reported that managers see the barriers to coding as technical, and believe that they can be overcome with training, which is a different perception from physicians, as reported above. 4 A small US study of community physician leaders and technical staff involved in EHR implementation and support, reported that both groups agreed on the key barriers to EHR adoption: (1) concerns over customisation; (2) perceived costs; (3) logistics and regulatory issues; (4) return on investment; and (5) integration issues

27 EHR Adoption: Perceived Barriers and Facilitators 7 Addressing Barriers: Recommendations from the Literature This literature review systematically documents barriers and facilitators related to EHR adoption from the perspective of health practitioners and other key stakeholders involved in EHR implementation and use. Moreover, it provides empirical evidence regarding common EHR adoption predictors and summarises common attitudes towards EHRs among different stakeholder groups. This information could be valuable for tailoring EHR adoption strategies to these different groups. As suggested in the literature, the identification of pre-existing barriers and obstacles, and the investigation of diverse concerns and perceptions of different stakeholder groups, are crucial steps 55, 56 in implementing change. Understanding the nature and cause of the concerns related to EHR implementation can greatly help inform change management strategies to overcome difficulties and potential barriers to EHR adoption. One surprising finding of the literature review was that concerns over privacy implications of EHRs were not found to be the most significant theme among most EHR stakeholders concerns, except patients. This suggests that patients concerns over privacy issues associated with EHRs might be fuelling the popular discussions on privacy issues reported in the news and grey literature. Successful initiatives, such as awareness campaigns and educational interventions designed to address privacy concerns associated with EHRs, would therefore have to be focused on this key stakeholder group. Some limitations of the evidence help put the literature findings into context. First, from methodological point of view, the evidence is inconsistent due to (1) varying EHR definitions; (2) varying quality of survey methodology; and (3) data collection based on self-report, with no auditing to confirm reported perceptions. Second, the majority of studies were conducted in the US, suggesting that some findings could be specific to the US healthcare context, that doesn t rely extensively on general practitioners (GPs) to deliver a broad range of services, as opposed to the other countries. In addition, the US context differs from other countries in the way primary care doctors are paid and in the fact that a high percentage of the population is uninsured. In spite of these differences, the findings suggest that most of the common themes reported in the US studies were present in studies from other countries. Table 2 on the next page provides a list of suggestions from the literature regarding strategies that can contribute to overcoming barriers to EHR adoption. A combination of awareness campaigns, educational interventions, training, incentives, along with enabling healthcare policies and national standards for security and data exchange, have been recommended to alleviate the barriers at personal and organisational levels. Most importantly, the literature findings suggest that EHR adoption is affected by a combination of barriers, facilitators and adoption predictors. Hence, change management strategies and interventions designed to increase EHR adoption need to follow a holistic approach, addressing the multitude of personal and organisational factors applicable to the specific stakeholder type and healthcare setting they are targeting. 27

28 EHR Adoption: Perceived Barriers and Facilitators Table 2: Summary of literature findings on suggested strategies for increasing EHR adoption THEME Literature Recommendations Barriers Addressed (i) Presence of an EHR Champion. A health practitioner champion or EHR problem solver at each practice is important to drive EHR adoption. The EHR champion doesn t have to be a traditional leader; it can be another team member who has emerged as the EHR problem solver for the practice. To help establish strong leadership, IT training should be provided to practice leaders and visits to successful EHR-based practices should be organised for those that are switching from a paper-based 1. Strong Leadership 2. Strong Project Management Techniques 3. Personalised, Effective Training and Education 4. Establishment of Standards 25, 37, 57 system. (ii) Mixed Leadership Style. No single leadership style is optimal a participatory, consensus-building style may lead to more effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation. 32 (i) Vision for the EHR. The project management team should obtain support from all stakeholders and ensure that the EHR vision is shared and understood by all. Organisations need to focus as much effort on this aspect as they do on the technical aspects of implementation. Clinical input in the IT planning process increases adoption of EHRs. 33, 57 2, 3, 7, 21, (ii) Broaden Support and Organisational Redesign. HPs need to accept that workload may increase in the short run. However, there needs to be continuous organisational reassurance that the increased burden will not continue in the long run and adequate support will be provided in the meantime to reduce perceived barriers. 57 (iii) Target EHR Adoption Strategies based on EHR Adoption Predictors. The EHR adoption predictors from the literature suggest that health practitioners are not a homogeneous group; EHR adoption strategies should be targeted to all of these different types of health practitioners. 58 (i) Role-tailored Training. Training workshops or continuing education should be designed to improve clinicians perceptions of EHR compatibility with existing processes and systems, and the availability of technical support. It has been suggested that training should be tailored 1, 3, 7, 57 to respective roles of the users in the clinical practice. (ii) Education Needs and Readiness for Change Assessment. Baseline levels of computer knowledge and readiness for change should be assessed, to estimate the length of time and amount of effort required to adopt the software into practice. In addition, those HPs that have expressed concerns about patient resistance to the EHR would benefit from training related to best practices in doctor-patient communication when an EHR is 37, used during consultations. (iii) Training Program Delivery. To address the concerns around a lack of time to attend training, it has been suggested to set aside time for implementation and training activities. Another suggestion was to reduce the patient load during early implementation. 37 (iv) Technical Support / Problem Reporting System. It has been suggested that extensive technical support should be available during the first month of implementation and users should have the ability to document system problems and receive prompt administrator feedback in the form 3, 57 of a responsive and helpful help desk. (i) Government initiatives should help shape the development of standards for security, data exchange and technology certification criteria. 59 Personal: Disruption of clinical workflow Lack of understanding of benefits Usability issues Lack of time Organisational: Financial Costs Software design and testing issues Implementation complications Personal: Disruption of clinical workflow Lack of understanding of benefits Usability issues Lack of time Negative impact on interactions Organisational: Software design and testing issues Implementation complications Lack of adequate IT resources Personal: Lack of understanding of benefits Confidentiality, Privacy and Security Issues Usability issues Lack of time Lack of computer skills Patient resistance Organisational: Software design and testing issues Implementation complications Personal: Confidentiality, Privacy and Security Issues Organisational: Lack of standardisation and interoperability 28

29 Perceived Barriers and Facilitators to EHR Adoption Appendix A: Summary of Included Studies Table 3: Summary of Included Studies of Perceived Barriers and Facilitators to EHR Adoption (51 papers) Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Abdolrasulnia Primary care physicians Survey (mailed, (n=2,926) non-validated) statistics (US, Florida) Community-based, primary care practices Excluded: hospital-based physicians with specialties in radiology, pathology, anaesthesiology and emergency medicine (pre- and postimplementation, depending on adoption status) February to May 2005 Self-reported EHR adoption by physicians (and data from other government data sources) Questions on: Adoption Use Barriers PDAs Computers EHR a paperless form of medical record that requires the provider to enter patient information into a computer system instead of doing so on paper Odds ratios Hierarchical Linear Modelling Adoption Predictors Physicians located in areas with higher physician concentration and more competition were found to be more likely to adopt EHRs. Practice size, years in practice, Medicare payer mix, and measures of technology readiness were found to independently influence physician adoption, with technology readiness being the strongest predictor of EHR adoption Bevis (Australia, Sydney) Patients (n=77) General practice Questionnaire (5-minute, administered in waiting room) March 3 to April 1, 2003 Attitudes towards computer use by GPs for clinical purposes during consultation EHR: Medical Director, for prescription writing and patient management + Attitudes: Doctor-patient communication Quality of care Overall consultation process - Attitudes : Lack of understanding about the computer s role during consultation Bryson (UK) Nurses, midwives and health visitors (n=2,020) ( 25% were staff nurses ) Survey (online) Perceptions, knowledge and expectations of the NHS EHR EHR: (part of the NHS modernization programme) Perceived Facilitators: Training Nursing staff were not widely aware of the EHR implementation plans Chisolm (US) Emergency physicians and nurses (n=71) (~62% of subjects were Survey (online) (3 waves postimplementation) Perceived user satisfaction and committed use EMR: includes documentation for physicians and nurses, laboratory Bivariate relationships Adoption Predictors: Perceptions of training and support Perceptions of usefulness Effort expectancy Social influence 29

30 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings nurses) and radiology Computer literacy November 2006 reports, CPOE, Affective feelings towards computers to July 2007 CDS Hospital emergency department and off-site urgent care centres Multivariate liner regression analysis Many perceptions of the EHR system at launch persisted through the first months of use, suggesting that early positive impressions of training, support, and belief and EHR usefulness can maximise EHR adoption. Dahm (Sweden) Nurses (n=85) Hospital Survey (online) Opinions about using standardised care plans in EHRs EHR: standardised care plan + Attitudes Standardised care plans: Increase nurses ability to provide the same highquality basic care to all patients Decrease documentation time and redundant documentation Training is needed. Nurses had positive attitudes towards use of standardised care plans and felt that they could facilitate nursing practice. DeLusignan (UK) GPs (n=5), Primary care nurses (n=5), Practice managers (n=5) Community physician offices Interviews (semi-structured) (postimplementation) Perceived barriers to recording structured information (coding) in EHRs EHR: coding aspect Thematic analysis Managers see the barriers to coding as technical. Clinicians see more socio-cultural factors. Perceived Barriers to Coding Clinicians found coding difficult due to too many detailed option in the classification, and the lack of definite meaning for each code. Primary care clinicians think that the definite diagnosis is often an anathema in primary care, and that it can also stigmatise patients or damage relationships. GPs concerns were around difficulties selecting a definite diagnosis, while nurses concerns were around the meaning and interpretation of the coding by the patients and the anxiety this may cause. Free text is a vital constituent of the EHR and should not be excluded. 30

31 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings DesRoches (US) Mixed physicians (from all specialties, who provide direct patient care, ~50% primary care) National Survey (mailed) Perceived barriers to adoption EHR Multivariate analyses (n=2,758) Mixed healthcare setting (community offices and hospital) (Excluded: osteopathy, residents, physicians working in federally owned hospitals, retired) (postimplementation) September 2007 March 2008 Relationship between EHR adoption and the characteristics of individual physicians and their practices Perceived Barriers Financial issues perceived as major barriers to adoption Not finding system that met their needs Uncertainty about their return on investment Concern that a system would become obsolete Perceived Facilitators Financial incentives for the purchase Payment for use of EHR Protecting physicians from personal liability for personal record tampering by external parties Adoption Indicators Primary care physicians and those practicing in larger groups, in hospitals or medical centres were more likely to use EHRs Gans (US) Group practices with three or more physicians practicing together with a common billing and EHR system (n=2,879) Mixed healthcare setting (community / hospital) National Survey (online, mailed, telephone) Interviews, site visits (pre- and postimplementation, depending on adoption status) January to February 2005 Rate and process of adoption of IT and EHRs Barriers to EHR adoption EHR statistics Regression analysis Adoption Predictors: Larger practices were more likely to have adopted EHRs than smaller practices Top 5 Perceived Barriers: Lack of support from practice physicians Lack of capital resources to invest in an EHR Concern about physicians ability to input into the EHR Concern about loss of productivity during transition to EHR Inability to easily input historic medical record data into EHR Georgiou (Australia) Hospital health professionals and staff (n=50) (doctors, nurses, managers, pharmacists, senior health executives) Interviews (semi-structured) (n=20) Focus groups (n=6) Main concerns of a broad range of hospital staff about the implementation of a CPOE CPOE Open coding of interview transcriptions Perceived Barriers Concerns about: Change in workflow practices Lack of adequate IT resources Software issues Negative impact on the patient-physician relationship Lack of time to acquire knowledge about systems 31

32 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Large Australian hospital (preimplementation) Senior staff predominantly in management (n=10) Senior clinical management staff (n=21) Predominantly clinical staff (n=19) January 2005 to February 2006 through training Lack of computer skills De-skilling Confidentiality, privacy and security concerns Financial concerns Implementation complications Clinical and management participants voiced analogous concerns with a similar level of frequency. Hackl (Austria, central region of Tyrol) GPs and specialists in private practice (n=8) Mixed healthcare setting (community offices and hospital) (surgeon, dermatologist, ophthalmologist, psychiatrist, gynaecologist, radiologist, 2 GPs) Interview Following the problem-centric method (preimplementation) Mid-2008 Concerns about the introduction of a nationwide EHR (ELGA) EHR Graphical networks were used to illustrate main categories Perceived Barriers - Motivated by negative emotions (anxiety and fear) regarding: Uncertainty regarding the implementation Lack of knowledge regarding EHRs Lack of tailored information for HPs Considerable additional workload and cost Change of accustomed workflows Additional workload due to information overload Unauthorised access to EHRs + Attitudes: Reduction of double examinations Possible reduction of healthcare cost Hellstrom (Sweden) Physicians (n=180) (from 7 out of 21 Swedish health care regions: primary care centres and hospital clinics of internal medicine, orthopaedics and surgery) Using 6 most widely used EHR/ePrescribing systems (Cosmic, Journal III, Survey (web) Questions on: Background: (8 items) Attitudes towards eprescribing: (19 items) (post- Attitudes towards eprescribing Comparison between frequent and infrequent users of eprescribing EHR: eprescribing module statistics Kruskal-Wallis test with Dunn s posttest + Attitudes: Easy to use Improved quality of care Time saving Safer, compared to handwritten prescriptions - Attitudes: Certain usability issues (price of drugs not clearly displayed, drug choice complicated, lack of receipt from pharmacy after successful transmission of an eprescription) Negative impact on the physician-patient relationship 32

33 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Melior, SYSteam Cross, Take Care, VAS) implementation) Extensive users of eprescribing had more positive attitudes towards eprescribing than rare users. Hier Physicians and residents Survey EHR (n=330) (mailed) statistics (US) Teaching hospital (Diverse multispecialty academic group practice with attached university hospital) (postimplementation) 38 items on demographics, computer experience and expertise, utility of EHRs, barriers to more effective use of EHRs Attitudes towards a new EHR system at the university Attitudes about EHRs (features, functionality, performance) Barriers to more effective use (perceptions of factors that they thought might limit the EHR) Means, standard deviations, Fisher exact test, Chisquare tests, analysis of variance, t- tests Perceived Barriers: Slow system speed / response time Inadequate IT resources Perceived Facilitators: Conservation of HP time, including time spent documenting care Steps need to be taken to ensure that EHR systems are built to facilitate the existing HP workflow User acceptance of the EHR was high for both faculty physicians (64.7%) and residents (88%). Computer literacy was high among respondents. +Attitudes: Increased availability of information Increased ability to communicate Increased legibility Easier to determine treating physicians Easier access to lab results Hunter (New Zealand) General public (aged 18+) (n=4,000) Survey administered by CATI telephone interviewing (national) Use of vignettes Early 2008 Public attitudes towards sharing confidential personal health information held in EHRs EHR Frequencies, chi-square tabulations Linear regression modelling 4 factors that have an impact on the public s attitudes were identified: Level of identification, Role of the person accessing the information, Reason for accessing it and; Typo of information requested. Cluster analysis 33

34 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Jha (US, Massachusetts) Mixed physicians (from all specialties) (n=1,345) Mixed healthcare setting (community offices and hospital) (excluding residents, retired or without direct patient care) Survey (mailed) (pre- and postimplementation, depending on adoption status) Between June and November 2005 Perceived barriers to adoption EHR systems Rates of EHR adoption Satisfaction with EHR systems Comparison between minority and non-minority serving physicians: EHR stats Bivariate comparisons, logistic regressions Perceived Barriers: Start-up and ongoing financial costs Training and productivity loss Lack of time to acquire knowledge about system Computer technical support +Attitudes: Improved access to up-to-date knowledge Improved interactions with healthcare team Reduction of medication errors Improved efficiency of providing care Improved quality of care -Attitudes: Privacy issues Rates of EHR Adoption: No evidence of digital divide, i.e. minority-serving providers did NOT have lower EHR adoption rates, faced different barriers to adoption or were less satisfied with EHRs. Comparison: High-minority providers were less likely to be concerned about the privacy and security aspects of EHR adoption than other practitioners. Jha (US) CIOs (n=2,952) Acute care hospitals National Survey (mailed) (pre- and postimplementation, depending on adoption status) March to September 2008 Relationship of adoption of electronic health records to specific hospital characteristics Perceived barriers to adoption Perceived facilitators EHR: both comprehensive systems and basic systems that include functionalities for physicians notes and nursing assessments. Logistic regression and multivariate models Perceived Barriers: Capital requirements and high maintenance costs (hospitals with EHRs were less likely to cite these barriers than hospitals without such systems) Unclear ROI Physicians resistance Inadequate IT staff Perceived Facilitators: Additional reimbursement for HIT use Financial incentives for implementation 34

35 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings of adoption. Technical support for implementation Objective EHR evaluation List of certified EHR systems Adoption Predictors: Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Recommendations: Financial support Interoperability Training of technical support staff Kaushal (US, Massachusetts) Mixed physicians Mixed healthcare setting ( ambulatory care, 15-39% primary care) (residents, retired excluded) (n=1,082) Statewide Survey (mailed) (pre- and postimplementation, depending on adoption status) June November 2005 Barriers to adoption and expansion of health information technology Comparison between users and non-users of EHRs: computer proficiency, physician and practice characteristics, availability of technology and financial considerations EHR: integrated clinical information system that tracks patient health data, and may include such functions as visit notes, prescriptions, lab notes, etc statistics Perceived Barriers: Lack of technical support Lack of industry standards Interoperability concerns High upfront costs Physician scepticism Adoption Pedictors (Profile of imminent adopters): Younger From practices with multiple physicians More experienced with technology More often in practices engaged in quality improvement Imminent adopters of EHRs differed from users and non-users. Kemper (US) Primary care paediatricians (n=526) Community physician offices Survey (mailed) (pre- and postimplementation, depending on 2 separate surveys: For those with an EHR in their practice : Functionality and use of EHR EHR: Computerised replacement of the paper medical chart as the primary source of statistics Pearson chisquare tests, Fisher s exact Perceived barriers: Most common among those with an EHR, before implementation: Cost Increase in physician workload Physician resistance 35

36 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings (Physicians practicing at adoption status) August to patient information. test Most common among those without an EHR: military facilities were excluded) November 2005 Cost Perceived benefits of EHR Reasons for and barriers to implementation Internet access Practice characteristics For those without an EHR in their practice : Attitudes regarding EHRs Future plans to implement an EHR Barriers to implementation Practice characteristics Inability to find EHR that meets needs Concerns about practice operation: physician resistance, system downtime, increased workload Lack of understanding of benefits +Attitudes: Improved practice operation (documentation completeness, access to patient records, communication with outside providers, office productivity, confidentiality and security) Results in long-term savings Improves quality of care Adoption Predictors: EHRs are concentrated in larger and networked paediatric practices. Comparison between EHR and non-ehr users Other: The lack of decision support in current electronic health records may limit the ability of these tools to improve care delivery. Kljakovic (New Zealand, Wellington Hospital and surrounding areas) GPs (n=79) and hospital specialists (n=120) (30 surgical specialists, 29 internal medicine specialists, 16 psychiatrists, 15 anaesthetists, 11 paediatricians, six obstetricians and Survey (mailed?) (postimplementation) June to August 2003 Doctor attitudes on diagnostic coding and information flow: Coding practice Training for coding Teaching experience in coding of diagnoses Attitudes to: Diagnostic coding Computerised clinical records EHR: diagnostic coding Perceived Barriers: Usability issues Comparison: There were marked differences in the attitudes of GPs and hospital specialists: Most GPs embraced computers and diagnostic coding, whereas few hospital consultants did so. Most doctors in both groups experienced considerable delay of information flow and favoured an electronic transfer of information. 36

37 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings gynaecologists, five oncologists, four Diagnostic problem lists psychologists, three radiologists and one microbiologist) Perceptions of information flow between hospital and general practice Barriers and virtues of diagnostic testing Comparison between GPs and specialists Kossman (US) Nurses (n=46) Hospital Questionnaire survey (openended questions), interviews, observations (postimplementation, 2 years) Perceptions of the impact of EHRs on work and patient outcomes EHR Perceived Barriers Slow system speed, system downtime and lack of adequate IT resources - Attitudes: EHR use is extensive and time-consuming Decreases time with patients, resulting in decreased quality of care + Attitudes: Increased access to patient information Increased efficiency Improved organisation Increased patient safety EHR has both positive and negative effects on patient outcomes; EHR both helps and hinders nursing work, but overall the nurses thought the benefits of EHR use outweighed its detractions. EHR is preferred over paper charts but should perform better to support nursing work. Nurses perceived that EHRs affected their work and patient outcomes. 37

38 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Leung (Hong Kong) Mixed physicians (from all specialties, representative of the general physician population of Hong Kong) Survey (mailed) Common barriers and facilitators associated with clinical computerisation Clinical computerisation Cluster analytic technique Mixed healthcare setting (community offices and hospital) (n=949) (pre- and postimplementation, depending on adoption status) 2001 Multivariate and canonical correlation analysis Perceived Barriers: Time costs (planning, purchasing, training and maintenance) Large capital investments and maintenance costs Lack of technical support Lack of knowledge and perceived difficulty in learning new technology Perceived Facilitators: Understanding of benefits (improved office efficiency, better quality health care, increased savings) Government financial incentives Adoption Predictor: Competitive peer pressure Other: EHR adoption predictors were linked to particular barriers or incentives respondents valued more Linder (US, Massachusetts) Primary care physicians (n=225) Mixed healthcare setting (community offices and hospital) (41% were interns, residents, and fellows) Survey (online) (postimplementation) Assess clinicians EHR use during patient visits Identify characteristics of clinicians who use the EHR intensively during patient visits Identify perceived barriers to EHR use during patient visits. Comparison between non-users and users (complete documenters EHR A majority of physicians do not fully utilise the EHR during patient visits. Perceived Barriers: Clinicians did not use the EHR during patient visits because of social, workflow, technical, and professional barriers: Loss of eye contact with patient Falling behind schedule Computers being too slow Inability to type quickly enough Feeling that using the computer in front of the patient is rude Preferring to write long prose notes There were no differences between users and nonusers based on age, gender, trainee status, self- 38

39 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings during patient visits) reported EHR experience, workload, or primary hospital affiliation. Loomis (US, Indiana) Family physicians (n = 618) Mixed healthcare setting (community offices and hospital) 17-28% hospital physicians Survey (mailed) (pre- and postimplementation, depending on adoption status) Differences in attitudes, beliefs, and demographic characteristics of EMR users and non-users EMR Z-test, Chisquare test Perceived Barriers: Data entry Cost Security and confidentiality issues Lack of understanding of benefits (useful tool to physicians, improved quality of care) There are large differences in the perceptions users and non-users of EHR systems. Adoption Predictors: Urban area Hospital-based Seeing fewer patients Menachemi (US, Florida) CIOs (n=95) Acute care hospitals Survey (mailed, validated) (pre- and postimplementation, depending on adoption status) Self-report data on : IT use Barriers to IT adoption Other IT and patient issues EMRs CPOE DS eprescribing ecommunication analysis Chi square, variance Adoption Predictors: Physicians active involvement in clinical IT planning Placement of strategic importance on IT by the organisation CIO involvement in patient safety planning Perception of an adequate selection of products from vendors. May to October 2003 Menachemi , 22 23, 24, 2007 Brooks (US, Florida) Primary care physicians (n = 4,203) (general internists, paediatricians, family physicians, general practitioners, and obstetricians/gynaecologi Survey (mail, validated and pilot-tested paper) (pre- and postimplementation, Barriers to EHR and adoption intentions Use of various information technology applications * Four separate papers EHR statistics Hypothesis testing Regression Adoption Predictors: significantly less likely to be in solo practice more likely to be an urban area more likely to be in a multi-specialty practice more likely to be practicing family medicine or obstetrics/gynaecology significantly less likely to consider upfront cost of 39

40 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings sts) depending on adoption status) Community physician offices (hospital-based physicians excluded) Spring 2005 including sub-analysis for: - child health providers (general paediatricians) - rural-urban differences - electronic communication and adherence to best practices - association of payer type (e.g. Medicare) and EHR use 24 models to detect relative difference between imminent adopters and other nonusers hardware/software, or to see an inadequate return on investment as a major barrier to EHRs Findings from sub-analysis: * Physicians caring for children (especially paediatricians) are significantly slower than other doctors to adopt EHRs * Rural doctors were less likely to use both and EHRs * Those in urban practices and larger practices reported higher use than those in rural practices and smaller practices. Those who had access to highspeed Internet and who used EHRs utilised more than those who did not have access * Practices that cater to a large number of Medicaid patients were less likely to have adopted an EHR system 25, 26 Miller 2004 (US) Primary care, physicians of all specialties and managers (n=26) (focus on EMR use by primary care physicians) Interviews (n=90) (semi-structured) (postimplementation) Mid-2000 to end of 2002 Barriers to adopting EMRs EMRs used for: Viewing Documentation and care management Ordering Messaging Analysis and reporting Patient-directed functionality Billing Patternmatching and explanationbuilding techniques Perceived Barriers: High initial cost and uncertain financial benefits High initial physician time costs Difficulties with technology Difficult complementary changes and inadequate support Inadequate electronic data exchange Perceived Facilitators: Financial incentives for quality Presence of an EMR champion More complementary changes and more intensive EMR use often were associated with greater quality of care and financial benefits. Morin (Canada) Seniors (n=30) Interview (Hour-long, using pilot-tested questionnaire) Participants views of the EHR in terms of consent, information and practice EHR, with quantitative and Opinions of seniors are generally favourable regarding the use of computers and the EHR in their presence. + Attitudes: 40

41 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Perceived advantages qualitative Being better informed components Trust and consideration for professionals Appreciation for innovation O Connell (US) Residents: paediatrics (n=45) and internal medicine (n=40) Teaching hospital Survey (some validated components) (postimplementation) Factors that influence acceptance of EHRs (satisfaction) EHR statistics Comparison between paediatrics and internal medicine residents -Attitudes: Internal medicine subjects were less likely to believe template-based documentation improved their efficiency. Majority (91%) of all subjects reported general satisfaction with the EHR implementation. Difference in satisfaction between subjects in the two specialties. Poon (US: Boston, Massachusetts Denver, Colorado) Stakeholders (n=52) from eight different areas: Integrated delivery networks Community standalone hospitals Skilled nursing facilities and rehabilitation hospitals Physician practices Home health agencies Pharmacies Reference laboratories Third-party payers Interviews with key stakeholders (by telephone) Discussions with panel of experts (pre- and postimplementation, depending on adoption status) Assess the level of adoption Document the major barriers to further adoption Comparison between 2 areas/markets (Boston vs. Denver) HIT statistics Perceived Barriers: Financial costs Loss of productivity EHR implementation complications Lack of data standards and interoperability, which may impact workflow and productivity, which in turn contribute to physicians resistance to adopt these systems. EHR implementation varied considerably across stakeholders. Authors recommend financial incentives to clinicians to use EHRs or pay-for-performance reimbursement Mixed healthcare setting (community offices and hospital) 41

42 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Pyper Adult patients Survey, Attitudes to EHRs EHR (n=1,050) focus groups statistics (UK, Oxfordshire) Rosenthal (US, North Carolina) Family physicians (n=182) Mixed healthcare setting (community offices and hospital) (in North Carolina, a poor area with underserved populations) Patients access to their online EHR Survey (mailed, validated) (pre- and postimplementation, depending on adoption status) Physicians utilisation and perceptions of health information technology (self-reported data) HIT: EHRs and applications associated with EHRs statistics Hypothesis testing +Attitudes: Patients should have the right to see their own record and control access to their records Adoption Predictors: Physicians in larger (10+ physicians) practices were more likely to utilise or be interested in utilising EHRs, word processing applications and the Internet. Digital divide exists for smaller physician practices in North Carolina. Rouf (US, Kansas) Medical students (n=33) Community physician offices (3 rd year, Ambulatory Medicine/ Family Medicine) Survey (online) October 2005 to February 2006 (postimplementation) Attitudes towards using the EHR in the ambulatory setting EHR +Attitudes: Improved organisation of information Improved documentation Decision support / Prompts to ask more history questions Perceived Barriers: Negative impact on the doctor-patient encounter Saleem (US) Primary care physicians (n=55) and nurses (n=35) Mixed healthcare setting (Primary care outpatient clinics of four geographically distributed VA medical centres; three were housed in hospitals)) Observation (postimplementation) January and June 2004 Barriers and facilitators to the use of computerised clinical reminders EHR (VA): Computerised reminders (CRs), a form of clinical decision support Ethnography Upward abstraction of qualitative field observations Barriers: Failure to redesign workflow resulting in a lack of coordination between nurses and providers, redundant documentation and the use of paperbased workarounds; Negative impact on patient-physician relationship: social norm for physicians to avoid using the computer while with the patient results in them using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; Lack of understanding of importance of CRs 42

43 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings (residents, nurse practitioners and physician assistants were also included) resulting in perceptions that it increases workload; Usability issues: redundant data entry and lack of CR flexibility; and poor interface usability. Facilitators: Conservation of physician time (limiting the number of reminders at a site; strategic location of the computer workstations); Changes in workflow (integration of reminders into workflow); and Technical support (the ability to document system problems and receive prompt administrator feedback). Schnipper (US) Scott (US, Hawaii) Patients (n=466) Primary care practices Senior clinicians (n=12), managers (n=5) and project team members (n=9) Mixed healthcare setting (four clinics and four specialty departments in one hospital) Survey (online) Interviews (semi-structured) (Postimplementation of CIS system, Preimplementation of EpicCare system) March to April 2003 Attitudes to patientaccessible EHR medications module Attitudes to implementaticoon of EMR during transition stage from between two EHR implementations (from CIS to EpicCare) Online patientaccessible medications module linked to EHR, designed to improve medication safety +Attitudes: Module was easy-to-use Improved access to accurate information by providers Improved patient preparedness for their next visits EMR Perceived Barriers: Lack of understanding of benefits associated with the selected EHR system (feeling that selection of EHR system was detached from local environment); Software design problems increased resistance; Loss of productivity, especially during initial implementation, which fuelled resistance; Concerns about shifts in work responsibilities, i.e. the system required clarification of clinical roles and responsibilities, which was traumatic for some individuals; Adoption Predictors: Local organisational culture, i.e. a cooperative culture created trade-offs at varying points in the 43

44 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings implementation; Recommendations: No single leadership style was optimal a participatory, consensus-building style may lead to more effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation; Changes in clinicians productivity may require both extra staff and the ability to make continuous adjustments during implementation. The process fostered a counter climate of conflict, which was resolved by withdrawal of the initial EHR system. Sequist (US) Primary care physicians, nurses and physician assistants (n=125) (79% physicians) Mixed healthcare setting (IHS Health Centres/clinics, 72% hospital-based) (Specialties: family practice medicine, internal medicine, paediatrics) Physicians serving minority populations with limited resources Survey (mail) (Postimplementation) (EHR system developed between 2003 and 2005, based on the system used by the Veterans Health Administration) Attitudes regarding EHR implementation Predictors of regular use Current utilisation of individual EHR functions Attitudes regarding the use of information technology to improve quality of care in underserved settings EHR based on the system used by the Veterans Health Administration (Indian Health Service (IHS) : providing health care to American Indian an Alaska Native tribes) statistics Multivariable logistic regression model Perceived Barriers: Clinical productivity loss Technical limitations of computers Availability of technical support Adoption Predictors: Increasing years since completion of clinical training Positive attitudes towards EHRs improving quality of care Clinicians support the use of IT to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the HIS, potentially due to limited use of key functions within the EHR. 44

45 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Simon , 35, Survey (mail) Perceived barriers to EHR adoption EHR stats (US, Massachusetts) Mixed physicians (from all specialities) (n=1,345) Mixed healthcare setting (Ambulatory setting: hospital-based, primary care, specialty care and solo practices) (excluded: residents in training, retired or without direct patient care responsibilities) 2008 paper: Additional survey of MAeHC physicians (n=355) before implementation of interoperable EHR system in March 2006, compared to state-wide survey discussed in 2007 papers (Preimplementation or postimplementation depending on EHR adoption status) Spring 2005 for 2007 papers September October 2005 for 2008 papers Attitudes towards HIT Predictors of use Comparisons of EHR adoption rates by: Specialty (primary care vs. other) Hospital affiliation Practice size Geography (urban vs. non-urban) Comparaison EHR adopters vs. nonadopters Regression models Adoption Predictors: Larger practices Other than primary care Affiliated with hospitals, especially teaching hospitals. Increasing years since medical school completion Seniority Understanding of EHR benefits Facilitators: Incentives for quality of care Perceived Barriers: Financial costs (start-up and ongoing) Loss of productivity Lack of uniform standards Lack of time to acquire knowledge about systems There is considerable variability in the functions available in EHRs and the extent to which physicians use them (e.g. largest gap for clinical decision support alerts, warnings, and reminders) Having EHR functions available does not always translate to regular use of them in day-to-day practice. Participants of MAeHC s demonstration program resembled physicians and practices across Massachusetts, supporting the notion that the results and lessons learnt will be generalisable to a statewide rollout using similar strategies and tactics. Terry (Canada) Family physicians (n=22), Nurses (n=9), Administrative staff (n=11), project management team (n=4) Interviews (semi-structured) Focus group (Post- Expectations of EHRs Time and training required to implement and adopt the software EHR/EMR Perceived Facilitators: User expectations of EHRs have to be examined before implementation Dedicated time for training is important. Implementing EHRs posed a substantial challenge for physicians both in meeting patients needs and 45

46 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings implementation) Mixed healthcare setting (community offices and hospital) Emergence of an EHR champion or problem solver Review of 3 qualitative studies Readiness of health care providers to accept the system in finding time for learning Having a champion or EHR problem solver is beneficial Baseline levels of computer knowledge influence the implementation process. Training is essential to bringing all users to the appropriate level of general computer knowledge, in addition to learning the specific EHR software Urowitz (Canada) CEOs (n=83) General and acute care hospitals Survey (online, national) (Preimplementation of PHRs) National readiness for the adoption and implementation of the EHR and PHR Organisational perceptions about providing patients with access to their records (PHR) PHR stats, cross tabulations Perceived Barriers (to providing patients with access to their own records): Most important barrier was financial resources Clinician buy-in: Providers less willing to provide access for patients to EHR Patient computer literacy Patient access to their records Valdes (US) Family physicians (n=5,517) Mixed healthcare setting (community offices and hospital) Survey ( , national) January 2003 (Preimplementation or postimplementation depending on EHR adoption status) Characterise users and non-users of EHR/EMR software Identify barriers to adoption EHR/EMR analysis Chi-square and t-tests Regression models Perceived Barriers: Financial costs Workflow barriers and loss of productivity Implementation complications Security and privacy issues No difference in EHR adoption was found across demographic groups (gender, urban/rural, region, or age group) More than 264 unique types of EHR/EMR software implementations found, suggesting low rate of standardisation, which becomes a major barrier to EHR adoption. 46

47 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Ventres Primary care physicians (n=23), office staff Interviews, Focus groups, Factors that influence how EHRs are used and EHR Perceived Facilitators for EHR use during patient visits: US members (n=12) and patients (n=52) Observations perceived in medical practice today during Ethnography Availability of financial resources necessary for continuing technical updates (postimplementation) physician-patient encounters Community physician offices (4 primary care offices using the same EHR software product) April 2001 to October 2003 Adequate IT resources: flat-screen monitors on mobile arms, convenient availability of computers at numerous locations in the medical office, in the hospital and at the homes of on-call physicians. Successful changes in workflow: ability of the physician to minimise EHR use during visits by reviewing patient records prior to the visit; physicians see the benefits of collaboration with patients and are willing to share the EHR screen with their patients Selection of suitable EHR: flexible EHR templates suitable for the complex social interaction in primary care; being able to record narrated notes in the EHR No interference with the physician-patient interaction: physician s style when alternating between computer use and patient communication does not have a negative impact on the interaction Understanding of benefits: acceptance by physicians and patients that the EHR is a newly introduced technology that is still in its embryonic stages of development ; organisational culture supportive of the EHR Vishwanath (US) Community physician leaders (specialties included family practice, internal medicine, pathology, paediatrics, and radiology) (phase 1, n=11; phase 2, n=16; phase 3, n=58) Focus groups (Phase 1: Brainstorming of EHR adoption barriers Phase 2: Sorting of barrier statements Phase 3: Barriers to EHR adoption along with the relative importance of each barrier EHR Concept mapping Perceived Barriers: Concerns over customization Perceived cost issues Logistics and regulatory issues ROI issues Integration issues Herd mentality/social influence Need for control Reimbursement issues 47

48 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Ratings of barrier Concerns over adopting new technology Technical staff (engaged statements) in IT implementation and support) (n=17) (postimplementation) Mixed healthcare setting (community offices and hospital) Westin (US) Whiddett (New Zealand) Wiljer (Canada) General public (aged 18+) (n=1,012) Patients (aged 18+) (n=203) Five primary care clinics Patients (n=46), Staff members (n=7) Haematology clinic at a hospital Survey (telephone, national) February 8 to 12, 2005 Questionnaire (paper) Questionnaire Attitudes towards EHRs EHR -Attitudes (concerns): Data security issues Unauthorised sharing of information Increase medical errors Non-disclosure of sensitive but necessary by patients due to concerns about EHRs Existing federal health privacy laws being reduced in the name of efficiency Attitudes towards sharing their health information held in EHRs Attitudes, preferences and needs of patients accessing their electronic health record EHR EHR Nonparametric statistical tests statistics 3 factors that have an impact on patients attitudes were identified: Identity of recipient, Level of anonymity of shared information Type of information requested. Patient Perceptions: Interested in using EHR, especially for accessing laboratory results Would require additional educational materials to understand information in their EHR Interesting in online communication with HPs Would like to be able to modify their data in the EHR Staff Perceptions: Perceived Barriers: Confidentiality, privacy and security issues Integration of new technology in existing systems Patient resistance 48

49 Perceived Barriers and Facilitators to EHR Adoption Author, Location Study Subjects, Setting Method Measurements HIT System Data Analysis Summary of Key Findings Providing adequate support and education Increase in time required to manage patients and more questions/phone calls Increased risks of breaches in security and confidentiality Perceived Benefits: Decreased workload Improved workflow Better management of patients Decrease in unnecessary hospital visits Zandieh (US, New York) Practice managers (n=11) and medical directors (n=12) Ambulatory care practices (n=12: internal medicine, obstetrics and gynaecology, paediatrics, geriatrics, family medicine) Large teaching hospital Interviews (semi-structured) January to May 2006 (Preimplementation or postimplementation depending on EHR adoption status) Perceived benefits and challenges in implementing a new ambulatory EHR system Similarities and differences between leaders perceptions in practices that had: 1. Legacy EHR systems (n=5) 2. Paper-based systems (n=7) EHR Perceived Barriers: Decreased productivity during implementation Practitioner resistance Lack of adequate IT resources Privacy and security issues Both practice managers and medical directors had similar concerns regarding practitioner productivity and training. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. Satisfaction +: Improved communication Remote access to health records Improved workflow processes as a result of automation 49

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